The  invasion  of  Robotics  in  Theatre

Mr Nikhil Vasdev

Consultant Urological and Robotic Surgeon Hertfordshire and South Bedfordshire Urological

Cancer Centre Lister Hospital

Senior Visiting Clinical Lecturer in Uro-oncology

University of Hertfordshire

Introduction

Medical  Robotics

Robotic  Urology   •  The widespread adoption of robotic technology over the

past decade has resulted in significant changes in the way numerous urological conditions are managed

•  Robotic devices continue to evolve and as they become less expensive and more widely disseminated – it is likely they will become more frequently utilized in an increasing number of surgical procedures

•  The rapid introduction of robotic procedures in urology

necessitates the need for the development of new training methods

1999 2000 2001 2002 2003

da Vinci® European Installed Base 1999 – 2012

2004 2005 2006 2007 2008 2009 2010-­‐‑12

da Vinci® USA Installed Base 1999 – 2012

Surgical  Advantages  of  Robotic  Surgery  

6  degrees  of  movement

Surgical  Advantages  of  Robotic  Surgery  

10  X  magnification 3  D  vision

Robotic  Prostatectomy  and  Lymph  node  dissection

Robotic  Partial  Nephrectomy

Nature  Reviews  Urology    2004 Technology  Insight:  surgical  robots Expensive  toys  or  the  future  of  urologic  surgery? ‘‘A Robot Saved My Life’’: Is It a Myth?

Premature Robotic Surgery: Putting Patients and Professionals at Risk

Robotic Surgery: Hope or Hype? Presidential Debate SAGES 2011

Will the Future of Health Care Lead to the End of the Robotic Golden Years?

•  Baseline problems in finding evidence for superiority

o  A Randomized clinical trial is not feasible because both expert surgeons and patients have their bias regarding the optimal technique

o  No level 1 evidence o  Different definitions – Positive margins, biochemical recurrence, urinary

incontinence and sexual function

o  Limited to single case series, systematic reviews and meta-analysis

o  Selection bias in these studies often from high volume, academic centers

Aim  of  robotic  prostate  cancer  surgery

ORP  /  LRP RRP

Trifecta   Pentafecta  

Disease  control Disease  control

Potency Potency

Continence Continence

Negative  Margins

Complications

Lister  Hospital  Robotic  Urology  Experience

•  3 Consultant Robotic Urological Surgeon (NV, JA, TL)

•  2 Consultant Anaesthetists (GMS, VP)

•  Theatre Team

•  Only National Robotic Urological Fellowship programme accredited by RCSEng / BAUS

Current  Achievements  Robotic  Urology  at  the  Lister  

Hospital  (2014)  

•  1 of 3 trust offering a full range of robotic urological surgery

o  Robotic Prostatectomy o  Robotic Cystectomy +

Intracorporeal Ileal Conduit / Neobladder formation o  Robotic Partial Nephrectomy o  Robotic Pyeloplasty o  Robotic Nephroureterectomy

Current  Achievements  Robotic  Urology  at  the  Lister  Hospital  

•  Only centre in the UK performing Intra-operative frozen section analysis of the prostate during robotic prostatectomy*

*My  Theses  for  MCh  (Urology)    –  University  of  Edinburgh  /  Royal  College  of  Surgeons  of  Edinburgh    06/2014

Activity  and  Referral  pa[erns  

•  Increase in Robotic activity by 25% over 12 months

•  Increase in 2 week wait cancer referrals by 27% over 12 months

68 73

67 66

79 73

81 78

69

87

72 76

54

86 79

99

85

75

111 114

98

108 114 111

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2012/13 2013/14

Robotic  Urology  in  the  NHS  2020    

•  Centralization of Cancer Services to 15 – 30 centres in the England [NHS England – Everyone counts (2014)]

•  Potential funding gap of £ 30 billion by 2020/21 [A Call to

Action (2013)]

•  Variable cost of Robotic system leasing and maintenance contracts [Intuitive Surgical (2014)]

Our  experience

Cost

Cost

Cost

Intuitive  sales

What  makes  robotic  surgery  expensive  ? •  The initial cost is extremely high, estimated to be about

$1.8 million and the maintenance costs •  After ten uses of a robot, the instruments must be replaced •  Use of the robot comes with a slower learning curve for

doctors. •  When hospitals attempt to balance patient safety with the

high training costs, sometimes poor patient outcomes occur.

•  There are also increased costs to the patient per surgery, estimated at around $2,500 per procedure compared to traditional methods

Robotic  prostatectomy  will  always  be  more  costly  to  the  NHS  because  of  the  fixed  capital  and  maintenance  charges    for  the  robotic  system Our   modelling   showed   that   this   excess   cost   can   be   reduced   if   capital   costs   of  equipment  are  minimised  and  by  maintaining  a  high  case  volume  for  each  robotic  system  of  at  least  100–150  procedures  per  year.  This  finding  was  primarily  driven  by  a  difference  in  positive  margin  rate

How  can  we  improve  robotic  theatre  efficiency  

Theatre  Robotic  Urology  Utilization  

Audit Urology – N Vasdev, S Cashman, S Elands,

S Brooks, D Hanbury, T Lane, G Boustead, J Adshead

Anaesthetics – Gowrie Mohan S, Venkat Prasad

Urology Theatre – J Ocampo, L Jones

Urology  Robotic  Theatre  Cycle

Time  patient  sent  for  theatre

Time  from  preoperative  area  to  theatre

Anaesthetic  start  time  to  theatre

Operative  time

Time  second  patient  sent  for  second  patient

Time  list  finishes

Patient  and  Methods •  N = 43 Robotic Urological Cases

•  August 2013 until February 2014

•  2 Groups of patients

o  Group 1 – List on which 1 Robotic Urological Case was performed (n=18) [40%]

o  Group 2 – List on which 2 Robotic Urological Cases were performed (n=25) [60%]

Time  from  “patient  sent”  to  arrival  in  theatre  

pre-­‐‑operative  area

•  Mean = 29.8 minutes •  Range = 10 – 95 minutes

20 20 15 15

18 15

65

14 18

15 15 10 10

13 20 19

72 78

90 95

10

30 25 25

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Time  from  Pre-­‐‑operative  area  to  Anaesthetic  

Room

•  Mean = 65.4 minutes •  Range = 10 – 126 minutes

10

30 15 20

67

95

115 125

95 95

126

73

11

62 78

87

12 28 25 22

10

70 80 85

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Comparison  of  total  time  in  pre-­‐‑operative  area  

when  patient  arrives  before  8  am  or  after  8  am

67

95

115

125

95 95

126

73

110

62

78

87

70

80 85

100

28 25

10

22 20 15

30

10 12

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Before  8  am

After  8  am

Anaesthetic  Time

Mean Anaesthetic Time = 61.8 minutes (Range 20 – 110)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

95

11

93

30 65 59 50

29

70

40 67

20

99 74 65 72 75

105

20 23

70 65 72

38 39

Operative  Time  

(Surgery  +  Time  to  recovery)  for  first  case

Mean operative time + Time to recovery = 3.6 hours (Range 2.45-4.5)

4.75

3.80

3.15

3.88 4.10

3.95 3.95

4.55 4.45

3.15

4.05 3.85

3.40

4.20

3.10

3.98

3.15

2.45

4.05 4.24

3.90

3.25

2.45

3.15 3.25

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Comparison  of  Anaesthetic  times

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

AM  case

PM  Case

One  Robotic  Case

78%

Two  Robotic  Cases

20%

Details  of  robotic  cases  completed  by  5  pm

Time  of  completion  of  theatre  list  

(Patient  leaves  theatre  at  5  for  recovery)

20%

68%

8%

4%

By  five

By  six

By  six.thirty

By  eight

Areas  of  improvement •  When 2 Robotic cases are performed only

20% of cases finish at or before 5 pm

•  There is significant variability in the following areas

o  Waiting time from pre-operative area to theatre before 8 am

o  Issues with nursing handover and time of sending for theatre need to be addressed (Swift Ward)

o  Theatre turn around time between cases needs to be evaluated

How  can  we  improve  robotic  surgical  outcomes •  Regulation of Training (National guidelines being

prepared - 2015)

How  can  we  improve  robotic  surgical  outcomes •  Simulation

o  Simulation and Technology enhanced Learning Initiative (STeLI) project o  SAGES / RAST (Robotic assisted surgical training) programme

•  Formal Fellowship training o  6 robotic fellowships in the UK o  Only one recognized by the RCS/BAUS

•  Strict audit of outcomes

How  can  we  improve  robotic  surgical  outcomes

STOP COWBOY ROBOTIC SURGEONS

Latest  developments •  Robotic image integration surgery (Imris)

medical)

Latest  Developments •  Haptic Feedback

Latest  Developments

Robotic  Surgery-­‐‑  Is  the  jury  out  ?

Conclusion •  Patients undergoing Robotic Urological Surgery appear to

have o  Lower blood loss o  Reduced surgical morbidity o  Equivalent oncological outcome

•  There is likely to be in an increase in robotic surgical procedures o  Functional and quality of life benefits to patients o  Demand to provide service

Conclusion “The Surgeon, Anaesthetist and

Theatre Team are most important determinant of robotic surgical

patient outcomes of peri-operative complications and length of stay”

L Klotz

“The aim now should be to evaluate the cost of robotic

surgery results in long term gain for patient”

J Meeks

“Efficiency  is  doing  things  right;  effectiveness  is  doing  

the  right  things”